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September 2007 — Vol. 2, No. 9

In This Issue

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Terms and Definitions

HRSA: An Agency of the US Department of Health and Human Services, the Health Resources and Services Administration, was created Sept. 1, 1982.  HRSA currently has 1,600 employees, and as of FY2007, a $6.4 billion budget. HRSA distributes approximately 90 percent of its funding in grants to U.S. States and territories, public and private health care providers, health professions training programs and other organizations. HRSA is the principal federal agency charged with increasing access to health care for those who are medically underserved. HRSA’s programmatic portfolio includes a range of programs or initiatives designed to increase access to care, improve quality, and safeguard the health and well-being of the nation’s most vulnerable populations.

Examples of HRSA programs/activities include:

FQHC and FQHC “look-alike”:

The term “Federally Qualified Health Center,” or FQHC, refers to three different types of clinics:

• Health Centers (HCs) funded under Section 330 of the Public Health Service (PHS) Act, including Community Health Centers (CHCs), Migrant Health Centers (MHCs), Health Care for the Homeless Health Centers (HCHs), and Public Housing Primary Care Centers (PHPCs); (Note: Information regarding HCHs and PHPCs is not included in this publication. Further information regarding these programs may be found at http://www.bphc.hrsa.gov)

• FQHC “Look-Alikes,” or FQHCLAs, that have been identified by HRSA and certified by CMS as meeting the definition of “Health Center” under Section 330 7 of the PHS Act, although they do not receive grant funding under Section 330; and

• Outpatient health programs / facilities operated by tribal organizations (under the Indian Self-Determination Act) or urban Indian organizations (under the Indian Health Care Improvement Act).

The FQHC program [enacted under the Omnibus Budget Reconciliation Act of 1989 (ORBA 89) and expanded under the Omnibus Budget Reconciliation Act of 1990 (OBRA 90)] provides for cost-based reimbursement under Medicare and Medicaid for legislatively specified services.

The FQHC program was a logical extension of the Community/Migrant Health Center (CHC/MHC) programs enacted in the 1960s and 1970s. The original CHC/MHC programs provided federal grants to community health centers (CHCs) or Migrant Health Centers (MHCs) for the care of uninsured individuals. These facilities received no special Medicare or Medicaid payments.

Congress created the FQHC program to allow special Medicare and Medicaid payments for CHCs and MHCs thereby ensuring that grant dollars intended for the uninsured were available for that purpose. In order to extend the CHC/MHC concept, Congress also authorized the special Medicare and Medicaid payments for clinics that operate in compliance with the requirements of the FQHC program, but that do not receive grant funding under Section 330 of the PHS Act. These clinics are commonly known as “Look-Alikes.”

Rural Health Centers (RHCs): The Rural Health Clinics Act (P.L. 95-210) was passed by Congress and signed into law by President Carter in 1977. The goal of this Act was twofold. First, the act encouraged the utilization of physician assistants and nurse practitioners by providing reimbursement for services these health professionals provided to Medicare and Medicaid patients, even in the absence of a fulltime physician.

Second, it created a cost-based reimbursement mechanism for services when provided at clinics located in underserved rural areas. An RHC must be located in an area defined by the U.S. Department of Commerce, Census Bureau as non-urbanized. The Census Bureau definition of a non-urbanized area is an area that is outside of an urbanized area. An urbanized area is defined as, “A densely settled territory that contains 50,000 or more people.”

Visit http://www.census.gov for additional information regarding the definition of an urbanized area that is used for location determinations under the RHC program. Final determination regarding location eligibility is made by the Centers for Medicare and Medicaid Services (CMS) regional offices.

The FQHC program bases the distinction between urban and rural on whether or not the area in which a clinic is located is part of a Metropolitan Statistical Area (MSA). An FQHC may be located in either an urban or rural area. A rural area is one which is outside of an MSA. The importance of whether a clinic is designated urban or rural is due to the difference in payment caps that exist for rural versus urban FQHCs.

News Briefs

Increase in Adverse Drug Events: A recent study that appeared in the Archives of Internal Medicine found that adverse drug events, reported to the U.S. Food and Drug Administration, rose between 1998 and 2005.  The report indicated that 467,809 serious adverse events were reported to the FDA during this time frame.  An “adverse drug event” is an event that results in death, birth defect, disability, hospitalization or was life-threatening or required intervention to prevent harm. Fatal adverse drug events increased from 5,519 to 15,107 during that seven-year period. The study found that pain medications and drugs that modify the immune systems were the drugs most frequently associated with fatal events.

Medical Specialties and Clinical Information Access:  A study from the Center for Studying Health System Change found that medical specialty physicians had more access to clinical IT data than primary care physicians.  Surgeons were at end of the list for access to clinical IT, such as patient notes and data exchange with other doctors. Variance in practice financial resources and information technology needs may explain the differences, said the study’s authors.



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SPECIAL EDITION- Community Health Organizations

In the United States, some 16 million individuals receive their medical care at a Community Health Organization or Community Health Center.

In this edition, the Digital Office looks at these patient care sites that offer care to the underserved population. Read on to find out more.


Update on Community Health Centers
Massachusetts League of Community Health Centers, Inc.

The Digital Office talked with Ellen Hafer, executive vice president and COO, of the Massachusetts League of Community Health Centers, Inc. in Boston, Mass. In the question-and-answer story, Ms. Hafer provides a look at what is happening with CHCs in Massachusetts.

1. With new emphasis from the government on community health centers, please provide your perspective on the value and role of CHCs?

2. From your Web site, I see that the Massachusetts League of Community Health Centers serves one out of every nine residents in the Commonwealth. Can you talk about the CHCs in Massachusetts and the services they provide?
Community health centers in Massachusetts have grown throughout the state to meet needs. You can find community health centers from Franklin County, the Berkshires, Fitchburg, Gardner, Holyoke and Springfield to the Outer and Mid Cape, from New Bedford and Fall River to Lowell, Lawrence and Peabody, in Worcester and Framingham, Boston neighborhoods and Quincy, Hull, and Brockton. Community health centers are there meeting the highest needs for care. Community health centers in Massachusetts provide core primary health care services as well as some specialty services, including obstetrics and gynecology and complementary services including nutrition, dental, mental health and substance abuse. Many centers have expanded their role to meet community needs including nursing homes, day care, and elder service plans for the frail elderly as an option to nursing homes, also home visiting, and case management.

3. What about the EMR in these CHCs? How is it being used to improve care for these patients?

4. What are the barriers that you see in implementing the EMR in CHCs in your state and across the nation?

5. What are your recommendations for connecting CHCs with the EMR - that is - how can the more than 1,000 CHC sites in the country somehow understand the value of - and then implement - the EMR?

“We need increased funding and investment from stakeholders to support EMR implementation and collaborative efforts at CHC,” said Ms. Hafer, “and to implement and manage the EMR to gain maximum value for our patient care and provider workforce.”

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It’s Not Just about the Technology

Leslie Spiece
Senior Project Manager
IT Business Solutions - Operations
Assurant Health, Milwaukee, Wis.

The contract has been signed for an ambulatory electronic medical record (EMR) system; the technology specifications have been determined and the system configuration planning is complete... and the implementation can begin. Right? Wrong…

…The implementation of an EMR can rock a clinic’s world. It’s not just a new computer system that is coming, but a whole new way of providing care. Changes in patient workflows, clinic processes and culture are integral to a successful system.

Workflows: Workflows that worked in a paper world may not work in an electronic world. For instance, simple visual cues for patient arrival, such as the paper chart being placed in a slot, are no longer available in a computerized world. How does the medical assistant know that a patient has arrived?

This is just one of many workflows that will change. How well the new workflows are analyzed, documented and implemented has a direct impact upon how well the clinic will perform with the new system. Life in the electronic world is not the same as it was in the paper world.

Processes: Patient workflows are not the only processes that are affected by an EMR. Administrative functions, such as health information management, billing, and scheduling are impacted.  How do these functions integrate with the new system? How does the electronic world affect these administrative processes?

Culture: No matter how organized the patient workflows and clinic processes are, if staff does not accept and use them, then the effort is for naught.  Stakeholders – providers, clinic staff, and administrative staff – need to be involved in how the clinic will ultimately function.  The long-term success of the new system is dependent upon how well the new processes and workflows are accepted.

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Community Health Organizations in New York

An interview with Neil Calman, MD, president/CEO, the Institute for Family Health, New York, NY

1. With new emphasis from the government on Community Health Organizations, please provide your perspective on the value and role of CHOs?

Community health organizations have a special and unique (unfortunately!) role in the US healthcare system. They are the only providers that have a regulatory obligation to care for all patients, irrespective of their ability to pay – and to construct delivery systems to support specialty, ancillary and pharmacy services for those patients as well – either on-site or through special referral relationships. 

Their governance – over 50 percent of the board must be users of the center who represent the socio-demographic mix in their patient base – guarantees that they are responsive to the needs of the communities they serve.   CHOs have provided national leadership in areas of workforce development, team care, quality improvement initiatives and clinical outcome reporting, which has been in place since the 1980s.

2. Can you talk about the CHOs within the Institute for Family Health and how the EMR is impacting patient care and population health?

The Institute has 15 community health centers in its network from lower Manhattan through the Bronx and up the Mid-Hudson Valley as far as Kingston New York, approximately 120 miles to the North. In addition, the Institute operates eight homeless health care sites and over 35 grant programs for special populations and projects.

The EMR has been absolutely essential to many patient care efforts including these (listed below) that come to mind as critically important.

a. The EMR enables the leadership to instantly review the quality of care of any provider as all of our patients’ records are available at any site

b. It enables us to report on over 40 ambulatory care quality indicators, identify best practice, and immediately see the impact of quality improvement activities on the performance of a provider, a site, or our whole delivery system

c. It enables us to increase the involvement of patients in their own health care by providing them printed summaries of each visit, of health education materials and of their progress over time

d. It enables us to interact with the health department regarding reportable diseases, immunization registry, and syndromic surveillance

e. It enables us to care for our patients as a population group, identifying those in need of particular preventive or chronic disease management interventions

1. What are the barriers that you see in implementing the EMR in CHOs in your state and across the nation?

I see a number of barriers.

a. Financial weakness of the organizations, which are undercapitalized and often live on the edge of financial solvency.

b. Lack of experienced personnel in IT

c. History of some bad experiences with IT vendors

d. Lack of a dominant health center health IT vendor to date so that a multitude of different systems are being used

e. Failure of CHCs to work together to solve IT issues. However, in the last few years, this challenge has become infinitely better with groups throughout the country working together.

f. Reimbursement systems MUST support the ongoing costs of these systems – amortization of loans taken to pay for them and ongoing maintenance and support costs.

4. What are your recommendations for connecting CHOs with the EMR - that is - how can the more than 1,000 CHOs in the country somehow understand the value of - and then implement - the EMR?

They already understand. They want to move in this direction but fear, lack of skilled personnel and lack of financial resources are major obstacles. There needs to be a long-term financial commitment to support these investments.

CHOs are balancing the critical need for EMRs against many other critical healthcare needs in their communities.

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HIMSS Sponsors NACH Conference and Education Sessions

HIMSS was a co-sponsor of the National Association of Community Health Care Association’s annual conference held at Hilton Anatole, Dallas Texas, Aug. 24-28.

“HIMSS attended and sponsored this event as part of our continued support of the efforts of community health centers to adopt EHRs and Health information technology,” stated Mary Griskewicz, HIMSS senior director of ambulatory information systems. HIMSS sponsored several education events at the conference: “Washington Update: Health Information Technology Policies and Initiatives,” and “The Evolution of Information Exchange in Health Care.”   

Elizabeth M. Duke, who is the administrator of the Health Resources and Services Administration (HRSA), announced $31.4 million in grants to help health centers prepare to adopt and implement electronic health records and other health information technology innovations.

At this event, 25 grants were released totaling more than $27 million to support implementation of EHRs at health centers and in networks that link multiple health center grantees. 

“HIMSS supports the leadership of HRSA and community health care organizations that will be implementing health information technology supporting their goal to provide access to quality healthcare for all,” said Ms. Griskewicz upon the announcement of the grants. The list of grantees is available online and appears in two tables in the news release.  

To learn more about HIMSS Ambulatory Community Health Organizations, visit the HIMSS Web site.

Contact Mary Griskewicz at HIMSS for more information.

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Study Looks at Community Health Centers and Medicaid Requirements

As part of its ongoing assessment of the impact of Medicaid documentation requirements enacted by Congress in 2006, The George Washington University School of Public Health and Health Services (GW SPHHS) compiled profiles documenting the experiences of community health centers across the country.  The details that emerged as part of the research, which is supported by the RCHN Community Health Foundation, illustrate the major and measurable impact the rules are having on access to care and health centers' operations.  Patients, particularly children and citizens, are facing barriers to continued service, and centers are experiencing the financial fallout. Snapshots of the case studies are available on the foundation Web site.

The preliminary findings of the study, released in May 2007, revealed the requirements are disrupting coverage for hundreds of thousands of health center patients, while delaying enrollment in Medicaid for potentially hundreds of thousands more.  GW SPHHS is now in the process of repeating the survey in order to provide updated results in fall 2007, when House and Senate Conferees are expected to meet to resolve differences in legislation that could ease these requirements.

Barriers to Access:

Rather than curtailing enrollment of ineligible individuals, the reforms are affecting American citizens and documented immigrants.  The policy has erected particularly daunting barriers to healthcare access for U.S.-born children and, ironically, for American Indians and Alaska Natives, whose tribal documents may not always be officially recognized by the federal government.

Financial Ramifications:

Because of significant delays in the Medicaid application and enrollment process, health centers suffer adverse financial consequences while they continue to serve patients awaiting coverage determinations.

View the interviews online.  

Download the initial report, "An Assessment of the Effects of Medicaid Documentation Requirements on Health Centers and Their Patients."

The updated results are expected in October.

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Vendor Update:
Center for Community Health Leadership

In this column, the Digital Office usually profiles a physician practice that has implemented the EMR using a specific vendor’s health IT system.  However, this month’s review looks at several technology companies that have come together to support the Center for Community Health Leadership, formed by Misys in June 2006, to facilitate EMR adoption and community-wide health information exchange. 

The Center for Community Health Leadership, an organization sponsored by Misys Healthcare Systems, is working with other hardware vendors - Dell Inc., Fujitsu and Lenovo – to offer computer equipment, including servers, laptops, desktops, tablet PCs and scanners, to the Center’s grant recipients at a significantly discounted price.


Leigh Burchell, director of the Center for Community Health Leadership

"The support of the Center grant program from Dell, Fujitsu and Lenovo, and the assistance that Intel is providing with pre- and post-live data analysis for the community value proposition, are invaluable to our success," said Leigh Burchell, director of the Center for Community Health Leadership.  "This recognition of the Center's innovative approach to solving some of the industry's challenges is not only gratifying to us, but also critical to expanding the impact of our work in the selected communities."

Physicians and healthcare organizations in communities receiving a grant of EMR from the Center will have the opportunity to purchase hardware to host their solutions at rates supporting the Center’s goals of fostering EHR adoption and clinical connectivity. The participation of the technology leaders in the program will expand the number of area physicians able to afford the cost of transitioning to electronic medical records and enable them to participate in the communities’ health information exchanges.

In January, the Center for Community Health Leadership announced that New Haven, Connecticut, was awarded the first community grant of healthcare software valued at approximately $3 million. With implementation and training services being provided at cost and the recently added support from hardware vendors, New Haven physicians will be able to make rapid progress in creating a connected healthcare community and achieving broad usage of electronic medical records as the implementation cycle of the project begins in the coming months. Dell, Fujitsu and Lenovo have committed to provide the same discounts to physicians within the other grant recipient communities selected by the Center in the future.

The Center for Community Health Leadership was launched in June 2006 by Misys Healthcare Systems to spearhead the widespread adoption of electronic health records on a community-by-community level. The Center announced its first grant recipient in January and will eventually provide grants totaling up to $10 million to communities across the country.


John Drury, M.D., CMIO of Saint Raphael Health System, New Haven, CT

"The most common reason we hear from area physicians related to why they haven't moved forward with electronic health records is the cost," said John Drury, M.D., CMIO of Saint Raphael Health System in New Haven, Conn., the first community selected for a grant from the Center for Community Health Leadership.  "The participants in the local initiative will benefit not only from the software being donated by the Center, but also the additional savings being facilitated by the hardware companies.  That support is going to make the project accessible to many more practices that would otherwise be able to join the project."

For additional information on the grant program from the Center for Community Health Leadership, visit www.misyscenter.com.  

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Thinking about Implementing Health IT...
Electronic Prescribing for the Medical Practice: Everything You Wanted to Know But Were Afraid to Ask

Hundreds of thousands of solo physicians and small group practices are looking at the dawn of emerging electronic prescribing technology that will improve safety, quality and efficiency.

To find out more about this book, go to the HIMSS Web site to “Meet the Author,” Patricia Hale, MD. Here, visitors can download and explore Chapter 1 and a valuable assessment tool from the book. 

This new title from HIMSS offers a concise step-by-step guide on planning, choosing, and implementing electronic prescribing for practicing physicians and their office staff.

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Already There...Implemented Health IT
Changing the Practice of Medicine at the University of New Mexico

The following story comes from a recent news release distributed by the University of New Mexico (UNM).  Project ECHO (Extension for Community Healthcare Outcomes) is a collaborative partnership of the UNM School of Medicine faculty, the New Mexico Department of Health and the State Department of Corrections that treats complex diseases in remote, rural and underserved communities. The University of New Mexico Health Sciences Center Project ECHO recently came in first in the international Changemakers competition to identify programs that are changing the paradigm of how medicine is practiced.     

The Changemakers Competition
In the competition, the Robert Wood Johnson (RWJ) and Askoha Changemakers looked for projects that fit the criteria of “disruptive practices.” Clayton Christenson, Harvard Business professor and author of “The Innovator’s Dilemma and The Innovator’s Solution,” defines a disruptive innovation as one that is so big that it eventually replaces, or disrupts, the established approach to providing that product or service.   

The two foundations sought an innovative approach in uncovering these disruptive medical programs.  Instead of following a traditional grant application and review process, they went online to sponsor the competition entitled “Disruptive Innovations in Health and Health Care:  Solutions People Want.”  The project attracted more than 300 entries from 27 countries.  At each point in the process, the proposals were open to public comment and discussion over the internet with UNM faculty responding to comments and answering questions regarding the project.   In the final round, health professionals all over the globe voted for their top three programs.  The programs are now eligible for some $5-million foundation funding from RWJ. Visit http://www.changemakers.net/en-us/competition/disruptive for more information the competition.

Project ECHO has been a pioneer in telehealth consulting between university specialists and community physicians throughout New Mexico treating Hepatitis C patients and is being used as a model for treating a number of complex, chronic illnesses in rural and remote areas. 

“It is gratifying that our project’s description was distributed around the globe,” said Sanjeev Arora, M.D., executive vice chair for the Department of Internal Medicine and director of Project ECHO.  

“*We competed with programs from some of the best medical schools in the US and the world including such names as Johns Hopkins, Stanford and Columbia University.  At each point in the process, we had the opportunity to discuss our program with health professionals and receive their comments.”

New Mexico leads the nation in deaths from chronic liver disease and cirrhosis and some 34,000 New Mexicans, including 2,500 prisoners, are infected with Hepatitis C. Prior to the launch of project ECHO, less than 1600 rural residents and no prisoners had received treatment for chronic liver disease.

Since its inception in June 2004, Project ECHO has established 21 HCV treatment centers in rural New Mexico and at prisons around the state, resulting in an additional 3,500 patients receiving disease management who otherwise would likely have received no treatment at all.

The key component of the ECHO model is a disruptive innovation called the Knowledge Network. In this “one-to-many” knowledge network, the expertise of a single specialist is “cloned” and shared with multiple primary healthcare providers, each of whom, in turn, sees numerous patients through telemedicine and internet connections.  This virtual team of UNM specialists has the potential ability over time to help treat thousands more patients than any one person could ever personally schedule and see.  

Knowledge under the model is a two-way street with community providers both learning - through individual case reviews and short presentations - and teaching through the shared case management of their patients.

Given the success of the program, additional ECHO clinics have been launched, in rheumatology, substance abuse, mental health disorders, HIV, high-risk pregnancy as well as cardiac disease risk reduction including diabetes, weight reduction and smoking cessation.

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